Violence & You
This Is A Quick Questionnaire and should take less than 60 seconds to complete
1. Have you been involved in a verbal (non-physical) confrontation in the past 12 months?
Yes
No
1.0 When did the incident take place?
Apr 1997
May 1997
Jun 1997
Jul 1997
Aug 1997
Sep 1997
Oct 1997
Nov 1997
Dec 1997
Jan 1998
Feb 1998
Mar 1998
Apr 1998
1.1. Did you believe that your aggressor(s) was ready/prepared to use physical violence?
Yes
No
1.2 Which of the following best describes the number of verbally aggressive individuals and the roles they played in the incident?
Individual acting alone
Individual acting as a primary aggressor with a non-aggressive partner present
Individual acting as a primary aggressor with an aggressive partner present
Two Individuals acting aggressively together
Individual acting as a primary aggressor within a relatively non-aggressive group
Individual acting as a primary aggressor within an aggressive group
Group of equally aggressive individuals
1.3 Which of the following best describes your relationship with the verbally aggressive individual(s)?
Stranger(s)
Distant associate(s) e.g. someone you recognise but don't know
Close associate(s) e.g. people you talk to but who don't know your peronal details
Friend(s) e.g. people who know your personal details
Ex-Intimate(s) e.g. people you have previously shared a physical/sexual relationhip with
Current intimate(s) e.g. people you currently share a physical/sexual relationhip with
Family member(s)
1.4. Which of the following do you believe best describes your verbally aggressive individual(s) motivations?
Sexual e.g. innapropriate advance etc
Financial e.g. asking for money etc
Fear e.g. afraid of you or the situation and so became aggressive
Anger e.g. perceived an injustice or wrong causing them to act
Ego e.g. needed to assert themselves in front of peers or to satisfy their own ego etc
1.5. Which of the following best describes the gender(s) of the verbally aggressive individual(s)?
Individual male or all male group
Individual female or all female group
Mixed group (even mix of male/female aggressor(s))
Mixed group (predominantly male aggressor(s))
Mixed group (predominantly female aggressor(s))
Unknown
1.6. Which of the following do you belive best describes the age or average age of the verbally aggressive individual(s)?
Under 14
15 - 19 Years of age
20 - 29 Years of age
30 - 39 Years of age
40 - 49 Years of age
50 Plus years of age
1.7. At what time of day did the verbally aggressive incident take place?
6pm - 9pm
9pm - 12am
12am - 3am
3am - 6am
6am - 9am
9am - 12pm
12pm - 3pm
3pm - 6pm
1.8. Which of the following best describes the location where the verbally aggressive incident took place?
Your home
Someone else's home or private place
Place of entertainment e.g. bar, pub, club etc
Residential street/Area
Commercial street/Area e.g. town/city centre, shopping area/mall etc
Open/Public Space e.g. park, woodland, sports field etc
Public Transport
Work
1.9. Which of the following do you believe best describes the length of time the verbally aggressive incident lasted?
Under 30 seconds
30 seconds - 2 minutes
2 - 5 minutes
5 - 10 minutes
10 minutes - 1 hour
Over 1 hour
2. Have you been involved in a physical confrontation e.g. a fight/assault in the past 12 months?
Yes
No
2.0 When did the incident take place?
Apr 1997
May 1997
Jun 1997
Jul 1997
Aug 1997
Sep 1997
Oct 1997
Nov 1997
Dec 1997
Jan 1998
Feb 1998
Mar 1998
Apr 1998
2.1 Which of the following best describes the number of physically violent individuals and the roles they played in the incident?
Individual acting alone
Individual acting as a primary aggressor with a non-aggressive partner present
Individual acting as a primary aggressor with an aggressive partner present
Two Individuals acting aggressively together
Individual acting as a primary aggressor within a relatively non-aggressive group
Individual acting as a primary aggressor within an aggressive group
Group of equally aggressive individuals
2.2 Which of the following best describes your relationship with the physically violent individual(s)?
Stranger(s)
Distant associate(s) e.g. someone you recognise but don't know
Close associate(s) e.g. people you talk to but who don't know your peronal details
Friend(s) e.g. people who know your personal details
Ex-Intimate(s) e.g. people you have previously shared a physical/sexual relationhip with
Current intimate(s) e.g. people you currently share a physical/sexual relationhip with
Family member(s)
2.3. Which of the following do you believe best describes your physically violent individual(s) motivations?
Sexual e.g. innapropriate advance etc
Financial e.g. asking for money etc
Fear e.g. afraid of you or the situation and so became aggressive
Anger e.g. perceived an injustice or wrong causing them to act
Ego e.g. needed to assert themselves in front of peers or to satisfy their own ego etc
2.4. Which of the following best describes the gender(s) of the physically violent individual(s)?
Individual male or all male group
Individual female or all female group
Mixed group (even mix of male/female aggressor(s))
Mixed group (predominantly male aggressor(s))
Mixed group (predominantly female aggressor(s))
Unknown
2.5. Which of the following do you belive best describes the age or average age of the physically violent individual(s)?
Under 14
15 - 19 Years of age
20 - 29 Years of age
30 - 39 Years of age
40 - 49 Years of age
50 Plus years of age
2.6. At what time of day did the physically violent incident take place?
6pm - 9pm
9pm - 12am
12am - 3am
3am - 6am
6am - 9am
9am - 12pm
12pm - 3pm
3pm - 6pm
2.7. Which of the following best describes the location where the physically violent incident took place?
Your home
Someone else's home or private place
Place of entertainment e.g. bar, pub, club etc
Residential street/Area
Commercial street/Area e.g. town/city centre, shopping area/mall etc
Open/Public Space e.g. park, woodland, sports field etc
Public Transport
Work
2.8. Which of the following do you believe best describes the length of time the physically violent incident lasted?
Under 30 seconds
30 seconds - 2 minutes
2 - 5 minutes
5 - 10 minutes
10 minutes - 1 hour
Over 1 hour
2.9. Which of the following best describes how the fight/physical assault started?
Push & upper body strike e.g. punch, elbow, headbutt etc
Grab & upper body strike e.g. punch, elbow, headbutt etc
Upper body strike e.g. punch, elbow, headbutt etc
Push & lower body strike e.g. kick, knee etc
Grab & lower body strike e.g. kick, knee etc
Lower body strike e.g. kick, knee etc
Some form of grappling attack e.g. headlock, choke, strangle, bearhug etc
Some form of weapon attack e.g. knife slash, knife stab, baseball bat swing etc
Some form of weapon threat e.g. knife placed against throat, gun placed against head etc
2.10. From what direction did the initial attack come from?
Physical attack from the front
Physical attack from the side
Physical attack from the rear
2.11. Which of the following best describes what (if any) weapons were used in the fight/assault?
No weapon
Bladed weapon e.g. knife, razor etc
Blunt weapon e.g. baseball bat, cosh etc
Short Barrel Firearm e.g pistol, revolver etc
Long Barrel Firearm e.g. shotgun etc
Improvised Weapon e.g broken bottle, chair etc
2.12. Which of the following best describes the time (if any) spent on the ground?
No time spent on the ground
Time Was Spent On The Ground Almost As Soon As The Fight Began
Time Was Spent On The Ground At Some Point(s) During The Fight
Time Was Spent On The Ground Only At The End Of The Fight
2.13. Which of the following best describes the way the aggressor/attacker approached you?
Ambush e.g. approached you with a pretence such as asking for change/the time/directions etc
Immediately displayed verbal aggression e.g. approached you making threats, challenges etc
Immediate Physical Violence e.g. made a physical assault with no verbal warning/display
2.14. Which of the following best describes the way the fight/assault ended?
Attacker/Aggressor Was Dominant Party
Victim/Target Was Dominant Party
2.15. Which of the following best describes the physical injuries that resulted from the fight/assault?
Minor e.g. not requiring medical attention
Major e.g. required medical attention
Extreme e.g. requiring (or will require) medical attention 3 months after the incident
2.16. Which of the following best describes the physical injuries that resulted from the fight/assault?
Minor Effect e.g. has hardly changed the way you view life or the way you lead it
Major Effect e.g. has altered certain aspects of your life – places you go etc
Extreme Effect e.g. has radically changed your outlook on life, society etc
3. Which of the following best describes your age?
15 - 19 Years of age
20 - 29 Years of age
30 - 39 Years of age
40 - 49 Years of age
50 Plus years of age
4. Which of the following best describes your gender?
Male
Female
Other
5. Which of the following best describes the location where you live?
Select Country Or Region
USA
Canada & Greenland
UK
Poland
Australia
Rest Of Europe
Middle East
South America
Australasia
Asia
Central America
Africa
